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Let’s Talk about a comprehensive mental health system

Psychiatric medications are valuable tools for treating many mental illnesses. Some psychiatric conditions, such as schizophrenia, can only be effectively treated with medication. However, pharmaceuticals have become the default treatment for all mental illnesses in Canada, even when the evidence suggests that medications are not effective for all of the conditions for which they are prescribed. For example, despite good evidence that anti-depressants have limited efficacy for mild to moderate depression, in practice they are still widely used as first-line treatment for these conditions. This is troubling, because for many of the most common mental illnesses – mild/moderate depression, anxiety and ADHD – the evidence for psychotherapy is as good or better than for medication. It’s cost-effective, too.

This isn’t to say patients shouldn’t be offered medications. The evidence tells us many of the most common illnesses may be best treated through a combination of medication and psychotherapy. However, too often it appears patients are only getting the pills, when guidelines are clear that psychotherapy (either alone or in combination with medication) should be first-line treatment.

So why exactly are psychiatric medications over-prescribed, while psychotherapy is under-utilized?

There are, of course, many reasons. One driver has been pharmaceutical manufacturers, who have promoted their products aggressively to both consumers and prescribers, with the goal of maximizing the return on investment for their shareholders. Without the same multi-billion dollar marketing budget, it’s not surprising that psychotherapy has a hard time competing with pharmaceuticals for attention.

But there are other drivers. The Canadian health care system itself reinforces the over-prescribing of medication and the under-utilization of psychotherapy.

Medical education is part of the problem. Graduating medical students are expected to be competent to prescribe an SSRI for depression, but they are not expected to be competent in administering cognitive behavioral therapy for the same condition. Family doctors, most of whom provide an enormous amount of mental health care as part of their practices, receive no routine training in psychotherapy as part of their residencies. Some individual doctors seek it out, but such training is not a matter of course.

But even if doctors get trained in psychotherapy, the system is designed to turn them into prescribing machines. Psychotherapy takes time; a lot more time than simply writing a prescription for medication. It is well documented that many regions of the country do not have enough family doctors; so in many regions, doctors must carry very heavy patient loads. Faced with the choice between twelve one hour sessions of CBT for a single patient or one fifteen minute appointment to write a prescription for an SSRI, most doctors feel forced to prescribe the pills so that they can see the rest of their patients. Psychiatrists are in the same boat. They must choose between providing a more effective treatment to a small number of patients, or providing a less effective treatment to a large number.

Ontario’s move to capitation for family doctors (paying doctors per patient instead of per service) has only made this problem worse, because if family docs wish to provide evidence-based but time-consuming psychotherapy, they will likely end up rostering fewer patients, which hurts them financially. We have essentially created a health care system that punishes doctors financially for providing evidence-based care.

But recognizing the pressure on doctors just highlights an even older problem: Canada does not have a comprehensive mental health care system. When Medicare was established, first in Saskatchewan and then nationally, it covered only physician services delivered in hospitals. While public health care has expanded since that time to include physician services delivered outside of hospitals, 30% of all health care spending in Canada is still financed privately. One of the areas still left out of Medicare is mental health services delivered by non-physicians.

Psychotherapy can be effectively delivered by appropriately trained clinical counsellors, clinical psychologists and social workers, yet none of these professions are covered by our “universal” health care system. As a result, patients with mental illness who cannot afford the services of these professionals must turn to a doctor (possibly at a walk-in clinic), who likely lacks either the time or the training to do anything but prescribe a medication. That the medication is covered by most provinces’ public drug plans for low-income earners and seniors just feeds the problem, since doctors know that if they write a poor or elderly patient a referral to a psychologist the patient probably won’t be able to afford it, but if the doc writes a prescription for a drug it will probably be covered.

If we are serious about getting over-prescribing under control and providing patients with evidence-based treatment for the most common mental illnesses, we must recognize that there are deep structural problems in our health care system that create barriers to providing the best care for patients. Evidence-based psychotherapy needs to become first-line treatment for mild to moderate depression, anxiety and ADHD (where appropriate for age, etc). To make this happen it must be covered under the public health care system regardless of what type of practitioner is providing this care. This is already happening on a small scale in Ontario’s Community Health Centres and Family Health Teams, but as good as these initiatives are they currently serve less than a quarter of the province’s population.

Could we afford such an expansion of Medicare? Yes, absolutely. International experience suggests that making psychotherapy first-line treatment could actually be cost saving, because we’re already spending the money on expensive prescription drugs that the evidence tells us don’t work as well.

We know over-prescribing is a problem. Let’s talk about how to solve it. Let’s talk about universal comprehensive evidence-based mental health care.

Enter the debate: reply to an existing comment

8 comments

Donna Elam PACFebruary 12th, 2013 at 9:57 am

Thank you. This is a very comprehensive and unbiased review of a very old problem. %featured%Now to rally solutions so that everyone gets what they need. Community based or grass roots solutions for patients like groups, community clubs etc for patients to partipate in theraputic relationships is happening but i believe could be expanded upon.%featured% In addition, the student or intern is also a good resource for support of those needing mental health therapy.

Excellent discussion about the importance of psychotherapy in the treatment of anxiety and depression. However there is more than just cognitive–behavioural therapy (CBT) that is Evidence-based psychotherapy for mild to moderate depression, anxiety.

You are absolutely right, Doug. My intention was only to use CBT as an example, not as an exhaustive list. And of course there are other non-CBT behavioural therapies that are indicated for ADHD. Thanks very much for clarifying!

%featured%Totally agree, universal comprehensive evidence-based mental health care is needed, with qualified mental health professionals deployed on the front lines, primary care psychologists and other qualified mental health professionals in Community Integrated Health Centers, comparable level of services for mental health as for medical care, mental health services accessibility/parity.%featured%
Psychotherapy is a variety of complex and powerful methods to assist people to overcome and manage symptoms of anxiety and depression; when tested with rigorous evaluation methods, in highly controlled environments, it has demonstrated its value to assist individuals to reduce anxiety and depression symptoms, increase functioning, and maintain the gains. These controlled studies have been performed under the supervision of highly qualified professionals who used and analyzed outcome measures.
For psychotherapy to be effective it has to be delivered by highly qualified professionals; an evaluation system to measure outcome needs to be integrated in the delivery of psychotherapy. Inappropriate psychotherapy can be ineffective and harmful to the vulnerable ones needing the assistance.Dr. Rafaela Davila, C.Psych.
Co-Chair, OPA Mental Health Accessibility Task Force
mhatf.blogspot.ca

This is a great piece Jeremy and really well lays out so many of the different issues at play here. I know working with a predominantly homeless population that the two social workers I have access to my in my Family Health Team are invaluable. %featured%I could attempt to treat their physical ailments all day without success if they weren’t getting appropriate counseling and therapy for their underlying trauma that often leads to mental health, addictions and homelessness.%featured% Sadly, having worked in various other inner city settings, I also know this type of access to counseling/therapy services is a luxury and I certainly agree that this is a huge gap in the Canada Health Act (along with universal access to medicines). Let’s hope we get there some day soon!

I have always felt that if their was a Provincial Mental Health entity similar to Cancer Care Ontario, we would serve these clients more effectively. Having been associated with CCO for a number of years I believe the template for establishing such an organization is already established. Mental Health Programes would be Evidenced based and monitored for effectiveness. Plus it would be a comprehensive service advocating for the most vulnerable clients in health care.

In 2004, I ran for the Alberta Green Party and I came across a report which led me to have conversations with the spokesperson for the Canadian Mental Health Association.

He described how the federal government had been waiting for ten years for a simple definition of mental health itself.

At the time, the government had given a final two years to come up with a mental health strategy to, at least, protect Canadians from the suicide tendencies that end up causing exponential damages in our world war against terror.

This morning on CPAC, I was listening to the spokesperson for the psychiatric association, addressing the Senate regarding their relation with pharmaceutical prescriptions and by the sound of it, we are still en(light)enment years away from knowing what mental health actually is and we have no idea who, where nor when the next suicide tendency can pop up like a sudden volcanic eruption of uncontrollable violence.

We all know that mental health is made of the love that produces justice, peace and joy but somehow, we have yet to discover how to deliver the surrender to such simplicity.

Soon, I pray and hope, community mental health services will get to join forces with restorative justice, to reach out with the passage from natural to spiritual that takes us from the divided spiritual subtraction of human DNA to the organic experience of spiritual unity.

This can be deployed as a comprehensive strategy through a 360 degrees municipal, provincial and federal social policy aimed at assembling Health – Education – Correction into a harmonized, circular flow of collaboration from home to school to play to work and back home deeper and stronger with each living moment.

In Canada, we can launch the strategy from Correction, reaching toward Health. In doing so, we can then get on with the transition from insanity’s fertile grounds of our history of denials, and enter into being and into treating one another as humans first, ahead of being separately Aboriginal, English, French or any other human.

Thanks for this piece Jeremy, on how mental health fits (or doesn’t quite fit) into our health care system. I appreciate the way you’ve described the context and laid out this important issue. As someone who recently started medical school, it’s really helpful to have some preliminary knowledge about these gaps in our health care system. So that I don’t take them for granted and am prepared to ask questions during my training. Thanks!

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.